Children s Specialized Hospital Neonatal Abstinence Syndrome (NAS)

Transcription

1 Children s Specialized Hospital Neonatal Abstinence Syndrome (NAS) A Pharmacologic and Rehabilitation Program that Promotes Narcotic Weaning and Autonomic Regulation Necessary for Infant Development Sharon A. Burke, MD Director, Infant Rehabilitation

2 Objectives Define Neonatal Abstinence Syndrome Identify some of the signs and symptoms of withdrawal List the medical management for an opiate exposed infant Discuss the rational for therapeutic intervention for a drug exposed infant

3 Setting the Stage for High Risk Newborns Infections Diabetes, Obesity IVF (superovulation) (10 15%) Pregnancy Induced Hypertension Maternal age: <17yrs and >35yrs Previous history of prematurity Uterine and Placental Indicators Illegal Drugs Prescription Medication Drinking, Smoking

4 Epidemiology: Public Health Issue 2009: Rate of NAS in the United States 3.9/1,000 (out of 4.1 million live births per year) > 41% of pregnant women report illicit drug use. > 71% of pregnant women report use of prescribed pain medications > 10% of pregnant women report use of prescribed psychoactive medications Withdrawal signs develop in 55 94% of exposed newborns. *2009 National Survey on Drug Use and Health. US Dept. of Health and Human Services.

5 Prescription Drug Use Among the Next Generation of Mothers 8% of teens, ages years, use prescription drugs. Pain medication: Vicodin, Oxycontin Antidepressant: Prozac, Zoloft Anti-Anxiety: Xanax Stimulants: Adderal, Converta * 2010: National Institute on Drug Abuse

6 Cost of Care National Aggregate: 2009 Mean Hospital Charges in 2009: $53,400 ($1,780/day) 78% of cost covered by Medicaid* * 2010: National Institute on Drug Abuse

7 Definition: Neonatal Abstinence Syndrome Constellation of behavioral and physiological signs and symptoms that occur in the newborn after the abrupt cessation of substances, most notably, Opioids. NAS due to prenatal maternal drug use that results in withdrawal symptoms in the newborn. NAS due to discontinuation of medications, such as Fentanyl or Morphine, used for pain therapy in the newborn. * Neonatal Drug Withdrawal, AAP 2012

8 Drugs Frequently Associated with NAS / Withdrawal Opiates and Narcotics Fentanyl, Morphine, Hydromorphone, Buprenorphine, Heroin, Methadone (Half- Life Hours) Codeine, Oxycodone, Pentazocine, Propoxyphene Other Drugs Barbituates (Half-Life Hours) Cocaine, Amphetamines (Half-Life <24 Hours) SSRI s, Antihistamines

9 Pathophysiology Illicit drugs can cause addiction in mother and physical dependence in the newborn, with passage of drugs across placental and CNS barrier. Drugs such as opiates cross maternal to fetal circulation quite readily, where they quickly accumulate due to immature liver metabolism and renal excretion. Abrupt discontinuation of drug at birth results in withdrawal in the newborn mitigated by increased Adenylyl cyclase activity with an abrupt rise in norepinephrine and subsequent autonomic symptomatology. Withdraw al is a function of half life: the longer the half life, the later onset of withdrawal.

10 Lab Studies Urine toxicity: Only provides maternal drug use history a few days prior to delivery up to 72 hours after birth. Meconium analysis: Can be used to detect maternal opioids and cocaine exposure after 1 st trimester up to 72 hours after birth. (Collected before contamination with formula). Hair analysis: Can indicate maternal use in the last trimester and up to 3 months postnatal life (Research laboratories). Umbilical cord tissue (immunoassay): Easy and rapid collection may foster its use.

11 Proposed Hypothesis for Expression of NAS Symptoms Methadone affects maternal vagal tone responsiveness. Fetal adaptation within the uterine environment to methadone induced changes in maternal vagal tone correlate with later newborn dysregulation of autonomic nervous system. Newborn autonomic instability may be moderated by both genetic and epigenetic factors. (Jansson, 2007)

12 Poor feeding, excessive sucking or rooting, Clinical Presentation of Autonomic Dysregulation CNS High pitched cry, restlessness, sleeps <1-3 hours. Hyperactive reflexes, tremors, myoclonic jerks. Hypertonia, convulsions, frequent sneezing, yawning. Vasomotor Sweating, mottling, temperature instability, apnea, fever, excoriation of skin. GI Disturbances

13 Finnegan Scale Scale assesses 21 signs of withdrawal, based on the following domains: CNS Vasomotor GI Disturbances Start pharmacotherapy for 3 scores of >8 Wean medications for 3 scores of <4 Score of 1 for least adverse effect. Score of 3 for most adverse effect.

14 Pharmacotherapy No optimum, absolute treatment established. Treat with medications in same drug class causing withdrawal. Opiate related and polydrug withdrawal. Morphine: full mu receptor agonist (0.03mg/kg q 4); shorter acting Methadone -full mu receptor agonist, longer acting, less fluctuation in levels at less frequent intervals; 0.05mg/kg q 6) (Buprenorphine Buprenorphine-partial mu receptor agonist ;shorter duration of treatment but potential ceiling effect in patients that may require adjunct therapy. Phenobarbital, -poly substance use; prolonged half life; adjunct therapy rather than primary treatment. Benzodiazepines for alcohol withdrawal, adjunct for calming. Clonidine as primary or adjunct therapy; reduces global sympathetic tone. less efficacious than opioids, 1 report SVT,3 Myocarditis,1 SIDS (Leikin Clinic Toxicol, 2009) NOTE: Tincture of opiate (0.1ml / kg q 4) and paregoric no longer recommended (due to additives, camphor, ethanol 46%; benzoic acid. * AAP Policy Statement: Neonatal Drug Withdrawal Pediatrics, 2012; 129

15 Long term mortality rate is low. Increased risk of SIDS : 3.7 fold increase risk in methadone exposed infants. 2.3 fold increase in cocaine exposed infants. Seizures Mortality and Morbidity 2-11% incidence of seizures in infants withdrawing from opioids. (Lacroix. Addiction, 2004) Breastfeeding encouraged except with Buprenorphone (buprenorphine and

16 Children s Specialized Hospital: Infant Rehabilitation Program for therapy based interventions for infant withdrawal.

17 Children s Specialized Hospital Neonatal Abstinence Syndrome (NAS) Program

18 Behavioral Epigenetics: Impact on development Confounding variables such as withdrawal of opioids, genetic dysmorphisms (adult addiction) and environmental factors may all play a role in the pathogenesis of Neonatal Abstinence Syndrome and subsequent developmental issues. Fetal adaptation to unfavorable uterine environment may present as maladaptive or inappropriate physiologic and/or behavioral responses to extra uterine life. (Jansson) That is, vulnerable prenatal experiences may shape / moderate post natal autonomic and developmental outcome. Lester, 2011

19 Pathophysiology of Developing Systems: Rationale for Rehabilitation Developing Neuronal Systems, especially opioid exposed, need experienced assessment, stimulation and interventional therapy to positively impact on development of the newborn beyond the pharmacologic treatment. Sensory recruitment of muscles Motor patterns Motor planning Cognitive processing Social interaction and integration Guidelines for opioid addiction in adults recommend comprehensive modalities: pharmacotherapy, behavioral modifications and psychosocial therapy. (Amer Soc Addiction Medicine,2001)

20 Healing it comes from the heart

21 Healing Environment

22 A Place Where Moms Can Relax

23 Aquatics for Tots: Soothing sensory input for calming, tone management and awareness.

24 Motor Patterns: Vital Stimulation Program to enhance feeding outcomes in medically fragile infants.

25 Motor Planning: Computer Mediated Learning Interactive modality stimulates infant motor response to sensory input.

26 Cognitive re enforcement: Computer Based Learning

27 Sensory Recruitment of Muscles: Infant Massage

28 Social Interaction and Integration: Group Therapy

29 Self calming strategies, music and positioning aids

30 Sensory stimulation for cognitive processing

31 Nutrition Small, frequent feedings to provide kcal/kg Monitor growth velocity NAS exacerbates symptoms of GER Consider high calorie formulas when infant irritability or fatigue interferes with feeding Consider tube supplementation in infants with dysphasia Feeding specialist: When required WIC Program registration. Breastfeeding is not contra indicated in mothers on Methadone, but not recommended in mothers on Suboxone by the manufacturer.

32 Coordination of Home Services Physician services (PMD, Specialists, Apnea Testing) Nursing (CPR and Formula Training Home Nursing Services or Medical Day Car Medical or Positioning equipment Car seat safety check WIC referral and registration Provide medications prior to discharge

33 NAS Program Outcomes: Infant Drug Screen: 32/33 97% Positive Opiates: 14/33 42% of patients Methadone: 17/33 52% of patients Cocaine: 4/33 12% of patients Benzodiazepine: 4/33 patients 12% of Polypharmacy including Subutex: 6/33 20% of

34 Outpatient therapy programs have shorter hospital stay, but longer Infant Medication: Admission and Discharge Medication on Admission: 33/33 100% Methadone: 17/33 52% of patients Morphine: 7/33 21% of patients Morphine and Ativan: 7/33 21% of patients Ativan: 1/33 6% of patients Phenobarbitol: 1/33 3.4% of patients No Medication at Discharge: 32/33 97%

35 NAS Program Outcomes: Normal Pneumogram: 32/33 97% Age appropriate weight gain: 33/33 100% Calorie dense formula: 14/33 34% Discharge Disposition ALOS 4 6 weeks * Home: 25/33 72% Foster: 5/33 17% Adoption: 1/33 3.4% Other facility: 1/33 3.4% Note- average duration of treatment in adult- 6 mos-2 years (Nicholls. 2010)

36 Bayley Assessment Total Motor Composite: 20% low average Refer to EIP Cognition: 15% low average range Refer to EIP Language: 40% low average range Refer to EIP 10% significantly delayed Refer to EIP Feeding: 5 7% refer to Outpatient Feeding Therapy * Gestational age > 36 weeks ** Mean age: 55 days of life

37 Outcomes: Program Services to Keep the Gains CSH Developmental Specialty Clinic and Follow up Bayley Assessment at regular intervals EIP services for therapy 11 sites for OP therapy DCP&P to monitor family environment VNA continued evaluation of patient CSH Pediatric Practice for patient and sibling CSH Medical Day Care

38 Outcomes: Press Ganey Parent Satisfaction PT, OT, Speech and Recreational Therapies all scored higher than the 94 th percentile with respect to parent satisfaction, compared to other pediatric facilities. 100 percent of parents were confident with their training and could independently render their child s care.

39 Children s Specialized Hospital: Extra Care. Extraordinary Results

40 References Pediatrics.2012: American Academy of Pediatrics: Neonatal Drug Withdrawal. Substance Abuse and Mental Health Services Administration Office of Applied Studies.2003 National Survey on Drug Use and Health NeoReviews.2009:10(5) Neonatal Abstinence Syndrome. Finnegan LP. Neonatal Abstinence Syndrome, pharmacotherapy and developmental outcomes. Neurobehavioral Tox Teratology.1986; 8: Doberczak TM. One year follow up of infants with abstinence associated seizures. Arch Neurology.1988:45: Greenspan. Pediatrics 2009 Neonatal Drug Withdrawal. AAP National Survey on Drug Use and Health. US Dept of Health and Human Services.2009

41 References Lester BM, et al. Behavioral epigenetic. Ann NY Accad Sci 2011; 1226; Janssen LM. Maternal; vagal tone in response to methadone is associated with neonatal abstinence syndrome severity in exposed neonates. J Mater Fetal Neon Med 2007; 20: Backs CH et al. Neonatal abstinence syndrome; transitioning methadone treated infants from an inpatient to outpatient setting. J Perinatology 2011; Aug (Epub ahead of print.) Oberlander TF et al. Pharmacologic factors associated with transient neonatal symptoms following prenatal psychotropic medication exposure. J Clin Psych.2004:65: Chambers CD et al. Selective serotonin reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn's Engl J Med 2006:354: Nicholls L. Journal of Managed Care Pharmacy: 16(1 b):14 21.